LECTURE NOTES

For Health Extension Trainees in Ethiopia

Introduction to Health Education

Meseret Yazachew
Yihenew Alem

Jimma University

In collaboration with the Ethiopia Public Health Training Initiative, The Carter Center,
the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education

November 2004
 Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.

Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter
Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.

Important Guidelines for Printing and Photocopying

Limited permission is granted free of charge to print or photocopy all pages of this
publication for educational, not-for-profit use by health care workers, students or
faculty. All copies must retain all author credits and copyright notices included in the
original document. Under no circumstances is it permissible to sell or distribute on a
commercial basis, or to claim authorship of, copies of material reproduced from this
publication.

2004 by Meseret Yazachew Yihenew Alem

All rights reserved. Except as expressly provided above, no part of this publication may
be reproduced or transmitted in any form or by any means, electronic or mechanical,
including photocopying, recording, or by any information storage and retrieval system,
without written permission of the author or authors.

This material is intended for educational use only by practicing health care workers or
students and faculty in a health care field.
 Acknowledgment

The development of this lecture note for training Health Extension

workers is an arduous assignment for Dr. Meseret Yazachew and
Dr. Yihenew Alem at Jimma University.

Essentially, it required the consolidation and merging of existing in

depth training materials, examination of Health Extension Package
manuals and the Curriculum.

Recognizing the importance of and the need for the preparation of the
lecture note for the Training of Health Extension workers THE
CARTER CENTER (TCC) ETHIOPIA PUBLIC HEALTH TRAINING
INITIATIVE (EPHTI) facilitated the task for Jimma University to write
the lecture note in consultation with the Health Extension
Coordinating Office of the Federal Ministry of Health.

Finally the Federal Ministry of Health would like to express special

words of gratitude for those who contributed and endeavored to the
development of this lecture note and to TCC/USAID for the technical
and financial support.

i
 Table of Contents

Content

Acknowledgement ........................................................................... i
Table of content.............................................................................. ii
List of abbreviations ...................................................................... vi
List of tables ................................................................................. vii
List of figures ................................................................................ vii
Introduction ................................................................................... ix

UNIT ONE: Introduction To Health Education

Objectives......................................................................................1
Health Education ...........................................................................3
Historical development ................................................3
Definitions ....................................................................4
Aims and Basic principles of Health Education ............7
Approaches to Health Education ................................10
Targets for Health Education ......................................10
Health Education settings ...........................................11
Who is responsible for Health Education? ..................11
Role of Health Educator..............................................12
Exercises ......................................................................................13

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UNIT TWO: Health And Human Behavior

Objectives.....................................................................................14
Introduction...................................................................................14
Definition of behavior and other related terms .............................15
Factors affecting human behavior ................................................17
The role of human behavior for prevention of disease .................22
Exercise ........................................................................................25

UNIT THREE: Working With Communities

Objectives.....................................................................................26
Introduction...................................................................................26
Definition of community ................................................................27
Concept of community participation .............................................27
Benefit of community participation ...............................................30
Helping people to organize: The role of Health Extension
Workers ...........................................................................31

UNIT FOUR: Health Communication

Objectives.....................................................................................35
Introduction...................................................................................35
What is communication? ..............................................................36
Why communication? ...................................................................36
Types of communication ..............................................................37

iii
Components of communication ....................................................38
Communication stages .................................................................41
Common communication approaches ..........................................49
Methods of communication ..........................................................49
Barriers to effective communication .............................................51
Characteristics of effective communication ..................................55

UNIT FIVE: Educational Methods And Materials

Objectives.....................................................................................57
Introduction...................................................................................57
Educational methods ....................................................................58
Individual............................................................58
Group .................................................................63
Teaching materials .......................................................................77
Audios ............................................................77
Visual aids .......................................................79
Mass media ..................................................................................84
Exercise ........................................................................................87

UNIT SIX: Training

Objectives.....................................................................................88
Introduction...................................................................................88
What is training? ..........................................................................89
Types of training ...........................................................................89
Phases of training.........................................................................89
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Exercise ........................................................................................94

UNIT SEVEN: Planning, Implementation and Evaluation Of Health

Education Programs

Objectives.....................................................................................95
Introduction...................................................................................95
Planning process ..........................................................................95
Information gathering ..................................................97
Defining and prioritizing problems ............................101
Setting goals and objectives .....................................103
Identifying and obtaining resources ..........................105
Selecting appropriate methods .................................107
Carry out and evaluate the project .............................................110
Development and implementing a project plan.........110
Evaluating the project ...............................................111
Exercise ......................................................................................113

UNIT EIGHT: Ethical Issues in Health Education

Objectives...................................................................................114
Introduction.................................................................................114
Definition ....................................................................................114
Basic Principles of Ethics ...........................................................115
Health extension workers responsibilities as a health educator .117
Exercise......................................................................................119

v
Reference: .................................................................................120

vi
 List of abbreviations

AIDS Acquired Immuno-Deficiency Syndrome

HE Health Education
HEWs Health Extension Workers
BCC Behavioral Change Communication
FGM Female Genital Mutilation
FP Family Planning
HIV Human Immunodeficiency Virus
HSDP Health Sector Development Program
IEC Information Education Communication
MOH Ministry of Health
PHC Primary Health Care
WHO World Health Organization
UNICEF United Nation Childrens Fund

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 List of tables

Table 4.1 Examples of failure at different communication

stages .........................................................................47
Table 5.1.Main characteristics of mass media and face-to-face
communication .........................................................85

List of figures

Fig.2.1. Levels of prevention of disease .......................................22

Fig.4.1. Complete communication model .....................................38
Fig.4.2. Communication stages ....................................................42
Fig. 6.1 Project planning cycle .....................................................96

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 Introduction

The impetus for writing this lecture note arose from two but
interrelated pressing demands. The primary reason is the
identification of community based health care approach, as a
strategy, by the MOH of Ethiopia which intern required the training of
Health Extension Workers (HEWs). In addition to the eight
components of HSDP identified during the 1st phase, HSDP II
included the training and deployment of HEWs who will be delivering
essential health care services at the grass root level. Reference
materials on health communication both as an aid for the training of
these groups of development workers as well as for future utilization
at the work places are scarce or absent so far.

Appreciating the critical necessity of this material, the Carter Center/

Ethiopian Public Health Training Initiative, requested Jimma
University to prepare and make it ready for the purpose.

Accordingly, the Department of Health Education & Behavioral

Sciences made utmost effort to produce the material within the
shortest time possible. We tried to include major topics on health
education and promotion taking into account the scope of the
beneficiaries and the essentiality of some titles. The first two chapters
deal with the concept and principles of health education and issues
related to health and human behavior. With the assumption that the
health extension workers are closely working with and for the
community, the general concept and ways of community participation

ix
is described in the 3rd chapter. The fourth chapter discusses on health
communication.

Educational methods and materials are purposely discussed relatively

in a more detail in chapter five to provide adequate alternatives for
the HEW in their effort of communicating issues on disease
prevention and health promotion to individuals and families at
household level. The 6th and 7th chapter addresses planning process
of health education programs and designing training sessions,
respectively. Working with the community is something to be carried
out with caution. Therefore, ethical issues and standards are
discussed in the last chapter.

The authors believe that, though this lecture note is primarily

prepared for HEWs as a reference material, other paramedical and
related health educators can find it useful.

During the writing, we have tried our best to utilize simple and
understandable terms so as to make its consumption easier at all
levels. Examples and illustrations from personal experiences and the
work of other colleagues were used to make the material more
palatable. Objectives of each topic in every chapter are outlined to
help readers anticipate some knowledge before going through the
section. Study questions are also forwarded at the end of every
chapter to serve as a self-test. Lastly, we would be grateful and
enthusiastic to receive any sort of feedbacks and comments on the
writing.

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 UNIT ONE
Introduction To Health Education

Objectives
At the end of this chapter, the trainees will be able to:
Explain the concept of Health.
Define Health Education.
State historical development of Health Education.
Describe objectives of Health Education.
State basic principles of Health Education.

Before discussing about health education, it is imperative to

conceptualize what health itself means. Health is a highly subjective
concept. Good health means different things to different people, and
its meaning varies according to individual and community
expectations and context. Many people consider themselves healthy
if they are free of disease or disability. However, people who have a
disease or disability may also see themselves as being in good health
if they are able to manage their condition so that it does not impact
greatly on their quality of life.

WHO defined health as a state of complete physical, mental, and

social well being and not the mere absence of disease or
infirmity.

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Physical health refers to anatomical integrity and physiological
functioning of the body. To say a person is physically healthy:
All the body parts should be there.
All of them are in their natural place and position.
None of them has any pathology.
All of them are doing their physiological functions
properly.
And they work with each other harmoniously.

Mental health - ability to learn and think clearly. A person with good
mental health is able to handle day-to-day events and obstacles, work
towards important goals, and function effectively in society.

Social health ability to make and maintain acceptable interactions

with other people. E.g. To feel sad when somebody close to you
passes away.

The absence of health is denoted by such terms as disease, illness

and sickness, which usually mean the same thing though social
scientists give them different meaning to each.

Disease is the existence of some pathology or abnormality of the

body, which is capable of detection using, accepted investigation
methods.

2
Illness is the subjective state of a person who feels aware of not
being well.

Sickness is a state of social dysfunction: a role that an individual

assumes when ill

Health Education

Historical development

While the history of health education as an emerging profession is

only a little over one hundred years old, the concept of educating
about health has been around since the dawn of humans. It does not
stretch the imagination too far to begin to see how health education
first took place during pre-historic era. Some one may have eaten a
particular plant or herb and become ill. That person would then warn
(educate) others against eating the same substance. Conversely,
someone may have ingested a plant or herb that produced a desired
effect. That person would then encourage (educate) others to use this
substance.

At the time of Alma Ata declaration of Primary Health Care in 1978,

health education was put as one of the components of PHC and it
was recognized as a fundamental tool to the attainment of health for
all. Adopting this declaration, Ethiopia utilizes health education as a
primary means of prevention of diseases and promotion of health. In
3
view of this, the national health policy and Health Sector
Development Program of Ethiopia have identified health education as
a major component of program services.

Definition

Health education has been defined in many ways by different authors

and experts. Lawrence Green defined it as a combination of learning
experiences designed to facilitate voluntary actions conducive to
health.

The terms combination, designed, facilitate and voluntary

action have significant implications in this definition.

Combination: emphasizes the importance of matching the multiple

determinants of behavior with multiple learning experiences or
educational interventions.
Designed: distinguishes health education from incidental learning
experiences as systematically planned activity.
Facilitate means create favorable conditions for action.
Voluntary action means behavioral measures are undertaken by an
individual, group or community to achieve an intended health effect
with out the use of force, i.e., with full understanding and acceptance
of purposes.

4
Most people use the term health education and health promotion
interchangeably. However, health promotion is defined as a
combination of educational and environmental supports for actions
and conditions of living conducive to health.

Various terms used for communication and health education

activities

Information, Education and Communication (IEC) is a term

originally from family planning and more recently HIV/AIDS control
program in developing countries. It is increasingly being used as a
general term for communication activities to promote health.
Information: A collection of useful briefs or detailed
ideas, processes, data and theories that can be used
for a certain period of time.
Education: A complex and planned learning
experiences that aims to bring about changes in
cognitive (knowledge), affective (attitude, belief, value)
and psychomotor (skill) domains of behavior.
Communication: the process of sharing ideas,
information, knowledge, and experience among people
using different channels.
Social mobilization is a term used to describe a campaign approach
combining mass media and working with community groups and
organizations.
5
Health extension is an approach of promoting change through
demonstration, working with opinion leaders and community based
educational activities.

Nutrition education is education directed at the promotion of nutrition

and covers choice of food, food-preparation and storage of food.

Family Life Education refers to education of young people in a range

of topics that include family planning, child rearing and childcare and
responsible parenthood.

Patient education is a term for education in hospital and clinic settings

linked to following of treatment procedures, medication, and home care
and rehabilitation procedures.

Behavior Change Communication (BCC): Is an interactive process

aimed at changing individual and social behavior, using targeted,
specific messages and different communication approaches, which
are linked to services for effective outcomes.

Advocacy: refers to communication strategies focusing on policy

makers, community leaders and opinion leaders to gain commitment
and support. It is an appeal for a higher-level commitment,
involvement and participation in fulfilling a set program agenda.

6
Aims and principles of health education

Aims
Motivating people to adopt health-promoting behaviors by
providing appropriate knowledge and helping to develop positive
attitude.
Helping people to make decisions about their health and acquire
the necessary confidence and skills to put their decisions into
practice.

Basic Principles

All health education should be need based. Therefore before

involving any individual, group or the community in health
education with a particular purpose or for a program the need
should be ascertained. It has to be also specific and relevant
to the problems and available solutions.

Health education aims at change of behavior. Therefore

multidisciplinary approach is necessary for understanding of
human behavior as well as for effective teaching process.

It is necessary to have a free flow of communication. The two-

way communication is particularly of importance in health

7
 education to help in getting proper feedback and get doubt
cleared.

The health educator has to adjust his talk and action to suit
the group for whom he has to give health education. E.g.
when the health educator has to deal with illiterates and poor
people, he has to get down to their level of conversation and
human relationships so as to reduce any social distance.

Health Education should provide an opportunity for the clients

to go through the stages of identification of problems,
planning, implementation and evaluation. This is of special
importance in the health education of the community where
the identification of problems and planning, implementing and
evaluating are to be done with full involvement of the
community to make it the communitys own program.

Health Education is based on scientific findings and current

knowledge. Therefore a health educator should have recent
scientific knowledge to provide health education.

The health educators have to make themselves acceptable.

They should realize that they are enablers and not teachers.
They have to win the confidence of clients.

8
 The health educators should not only have correct information
with them on all matters that they have to discuss but also
should themselves practice what they profess. Otherwise, they
will not enjoy credibility.

It must be remembered that people are not absolutely without

any information or ideas. The health educators are not merely
passing information but also give an opportunity for the clients
to analyze fresh ideas with old ideas, compare with past
experience and take decisions that are found favorable and
beneficial.
The grave danger with health education programs is the
pumping of all bulk of information in one exposure or
enthusiasm to give all possible information. Since it is
essentially a learning process, the process of education should
be done step-by-step and with due attention to the different
principles of communication.

The health educator should use terms that can be immediately

understood. Highly scientific jargon should be avoided.

Health Education should start from the existing indigenous

knowledge and efforts should aim at small changes in a graded
fashion and not be too ambitious. People will learn step by step
and not everything together. For every change of behavior, a

9
 personal trail is required and therefore the health education
should provide opportunities for trying out changed practices.

Approaches to health education

The persuasion approach deliberate attempt to influence

the other persons to do what we want them to do (DIRECTIVE
APPROACH)
The informed decision making approach-giving people
information, problem solving and decision making skills to
make decisions but leaving the actual choice to the people.
E.g. family planning methods
Many health educators feel that instead of using persuasion it is
better to work with communities to develop their problem solving skills
and provide the information to help them make informed choices.
However in situations where there is serious threat such as an
epidemic, and the actions needed are clear cut, it might be
considered justified to persuade people to adopt specific behavior
changes.

Targets for health education

Individuals such as clients of services, patients, healthy

individuals
Groups E.g. groups of students in a class, youth club
Community E.g. people living in a village

10
Health education settings

When considering the range of health education interventions, they

are usually described in relation to different settings. Settings are
used because interventions need to be planned in the light of the
resources and organizational structures peculiar to each. Thus, health
education and promotion takes place, amongst other locations, in:
Communities
Health care facilities
Work sites
Schools
Prisons
Refugee camps etc

Who is responsible for health education?

Health education is the duty of everyone engaged in health and

community development activities. Health Extension Workers are
primarily responsible in working with the families and community at a
grass root level to promote health and prevent disease through
provision of health education. If health and other workers are not
practicing health education in their daily work, they are not doing their
job correctly. When treating someone with skin infection or malaria, a
health worker should also educate the patient about the cause of the
illness and teach preventive skills. Drugs alone will not solve the
11
problems. Without Health Education, the patient may fall sick again
from the same disease. Health workers must also realize that their
own personal example serves to educate others.

Role of health educator

Talking to the people and listening of their problems

Thinking of the behavior or action that could cause, cure and
prevent these problems.
Finding reasons for peoples behaviors
Helping people to see the reasons for their actions and health
problems.
Asking people to give their own ideas for solving the problems.
Helping people to look as their ideas so that they could see which
were the most useful and the simplest to put into practice.
Encouraging people to choose the idea best suited to their
circumstances.

12
Exercise

1. Define health and health education?

2. Explain why voluntary actions are so important in health
education programs.
3. List health education settings found in your locality.
4. Mention five basic principles of health education.

13
 UNIT TWO
Health And Human Behaviour

Objectives

At the end of this chapter, the trainees are expected to:

Define behavior and related terms
Describe the factors which affect human behavior
Discuss on the role of human behavior in prevention of disease
and promotion of health.

Introduction

In the previous section, we have tried to discuss the concept of health

and health education. Human behaviour is among the major
determinants of the health of individuals, families or communities.
Healthy behaviours contribute to the overall health of individuals and
communities and unhealthy behaviours adversely affect the quality of
life people at different levels. Most health issues cannot be dealt with
by treatment alone. The promotion of health and prevention of
diseases will usually involve some changes in life styles or human
behaviour.

14
Definitions of behaviour and other related terms

Behaviour is an action that has a specific frequency, duration and

purpose whether conscious or unconscious. It is what we do and
how we act. People stay healthy or become ill, often as a result of
their own action or behaviour. The following are examples of how
peoples actions can affect their health:
Using mosquito nets and insect sprays helps to keep mosquito
away.
Feeding children with bottle put them at risk of diarrhoea.
Defecating in an open field will lead to parasitic infection.
Unsafe sex predisposes people to unwanted pregnancy,
HIV/AIDS and other STDs
In health education it is very important to be able to identify the
practices that cause, cure, or prevent a problem.

The words actions, practices and behaviours are different words of

the same thing.
Life style: refers to the collection of behaviours that make up a
persons way of life-including diet, clothing, family life, housing and
work.
Customs: It represents the group behaviour. It is the pattern of action
shared by some or all members of the society.
Traditions: are behaviours that have been carried out for a long time
and handed down from parents to children.

15
Culture: is the whole complex of knowledge, attitude, norms, beliefs,
values, habits, customs, traditions and any other capabilities and
skills acquired by man as a member of society.

Distinguishing characteristics of culture

Culture is symbolic. It is an abstract way of referring to,

and understanding ideas, objects, feelings or behavior
the ability to communicate with symbols using language.
To convey new ideas people may invent single words to
represent many different ideas, feelings or values.
Culture is shared. People in the same society share
common behavior patterns and ways of thinking through
culture. For example people living in a society share the
same language, dress in similar styles, eat much of the
same food and celebrate many of the same holidays.
Culture is learned. A person must learn culture from other
people in a society. For instance, people must learn to
speak and understand a language and to abide by the
rules of a society.
Culture is adaptive. People use culture to adjust flexibly
and quickly to changes in the world around them. For
instance a person can adjust his diet when he changes an
area of residence.

16
Examples of behaviours promoting health and preventing
diseases

Healthy behaviours: - actions that healthy people undertake to keep

themselves or others healthy and prevent disease. Good nutrition,
breast feeding, reduction of health damaging behaviours like smoking
are examples of healthy behaviours
Utilization behaviour: - utilization of health services such as
antenatal care, child health, immunization, family planningetc
Illness behaviour: - recognition of early symptoms and prompt self-
referral for treatment.
Compliance behaviours: - following a course of prescribed drugs
such as for tuberculosis.
Rehabilitation behaviours: - what people need to do after a serious
illness to prevent further disability.
Community action: - actions by individuals and groups to change
and improve their surroundings to meet special needs.

Factors affecting human behaviour

1. Predisposing factors: provide the rationale or motivation for the

behavior to occur. Some of these are:
Knowledge
Belief
Attitudes
Values
17
E.g. For an individual to use condom, he has to have knowledge
about condom and develop positive attitude towards utilization of
condom.

Knowledge is knowing things, objects, events, persons,

situations and everything in the universe. It is the collection
and storage of information or experience. It often comes from
experience. We also gain knowledge through information
provided by teachers, parents, friends, books, newspapers,
etc
E.g. knowledge about methods of prevention of HIV

Belief is a conviction that a phenomenon or object is true or

real. Beliefs deal with peoples understanding of themselves
and their environment. People usually do not know whether
what they believe is true or false. They are usually derived
from our parents, grandparents, and other people we respect.
Beliefs may be helpful, harmful or neutral. If it is not certain
that a belief is harmful, it is better to leave it alone.
For example, a certain society may have the following beliefs:
Holding materials made of iron by mothers during
postpartum (Neutral)
Diarrhea may end up with death (helpful)
Measles can not be prevented by immunization
(harmful)

18
 Attitudes are relatively constant feelings, predispositions or
set of beliefs directed towards an object, person or situation.
They are evaluative feelings and reflect our likes and dislikes.
They often come from our experiences or from those of people
close to us. They either attract us to things, or make wary of
them.
E.g. w/o Almaz had fever and visited the nearby health center.
The staff on duty that day was very busy and shouted at her,
Do you want us to waste our time for a mild fever? Come back
when we are less busy. She did not like being shouted at. This
experience gave her bad attitude toward the health staff. This
bad attitude could discourage her from attending the health
center next time she is sick.

Values are broad ideas and widely held assumptions

regarding what are desirable, correct and good that most
members of a society share. Values are so general and
abstract that they do not explicitly specify which behaviors are
acceptable and which are not. Instead, values provide us with
criteria and conceptions by which we evaluate people, objects
and events as their relative worth, merit, beauty or morality.
E.g. being married and having many children are highly
valued in most Ethiopian community.

19
 Norms are social rules that specify appropriate and
inappropriate behavior in given situations. They tell us what
we should and must do as well as what we should not and
must not do.
For Example,
We often regard greeting as a social norm to be
conformed among members who know each other.
Murder, theft and rape often bring strong disapproval.

2. Enabling factors: these are characteristics of the environment

that
facilitates healthy behavior and any skill or resource required
to attain the behavior. Enabling factors are required for a
motivation to be realized.

Examples of enabling factors include:

Availability and or accessibility of health resources
Government laws, priority and commitment to health
Presence of health related skills

E.g. Enabling factors for a mother to give oral rehydration solution to

her child with diarrhea would be:
Time, container, salt, sugar
Knowledge on how to prepare and administer it

20
 In general, it is believed that enabling factors should be available for
an individual or community to perform intended behavior.

Behavioral intention Behavioral change

Enabling factors
(Time, money and materials, skills, accessibility to health services)

Behavioral intention is willingness/ readiness to perform a certain

behavior provided that enabling factors are readily available.

3. Reinforcing factors: these factors come subsequent to the behavior.

They are important for persistence or repetition of the behavior. The
most important reinforcing factors for a behavior to occur or avoid
include:
Family
Peers, teachers
Employers, health providers
Community leaders
Decision makers

We are all influenced by the various persons in social network.

Pressure from others can be a positive influence to adopt health
promoting practices as well as an obstacle. Influential people

21
significant influence to change others. In the case of a young child, it
is usually the parents who have the most influence. As a child grows
older, friends become important and a young person can feel a
powerful pressure to conform to the peer group.
E.g. a young man starts smoking because his friends encouraged him
to do so.

The role of human behavior in prevention of disease and

promotion of health

What is prevention?

Prevention is defined as the planning for and the measures taken to

forestall the onset of a disease or other health problem before the
occurrence of undesirable health events. There are three distinct
levels of prevention: primary, secondary, tertiary prevention.

Healthy person Early signs Disease Death

Primary Secondary Tertiary

prevention prevention prevention

Fig. 2.1 Levels of prevention of disease

22
Primary prevention

Primary prevention is comprised of those activities carried out to keep

people healthy and prevent them from getting disease. Examples of
important behaviors for primary prevention includes using rubber
gloves when there is a potential for the spread of disease, immunizing
against specific diseases, exercise, and brushing teeth. And any
health education or promotion program aimed specifically at
prevention of the onset of illness or health problems is also an
example of primary prevention.

Secondary prevention

Secondary prevention includes preventive measures that lead to an

early diagnosis and prompt treatment of a problem before it becomes
serious. It is important to ensure that the community can recognize
early signs of disease and go for treatment before the disease
become serious. Health problems like tuberculosis can be cured if the
diseases is detected at an early stage. The actions people take
before consulting a health worker, including recognition of symptoms,
taking home remedies (self-medication), consulting family and
healers are called illness behaviors. Illness behaviors are important
examples of behaviors for secondary prevention.

23
Tertiary prevention

Tertiary prevention seeks to limit disability or complication arising

from an irreversible condition. Even at this stage actions and
behaviors of the patient are essential. The use of disability aids and
rehabilitation services help people from further deterioration and loss
of function. For example, a diabetic patient should take strictly his/her
daily insulin injection to prevent complications.

24
Exercise

1. Identify helpful, neutral and harmful beliefs in your locality.

2. Discuss the enabling factors for latrine construction by a
family, and contraception use by a woman.
3. Give examples of important human behaviors, which
contribute to primary, secondary and tertiary prevention of
diseases.

25
 UNIT THREE
Working With Communities

Objectives

At the end of this chapter, the trainees will be able to;

Explain the concept of community and community

participation, in public health in general and health
education and promotion in particular.
Describe the benefits of community participation in the
achievement of health education programs.
Explore the mechanisms of achieving community
mobilization for common goal and the role of community
leaders towards such an endeavor.

Introduction

In the past, health education follows persuasion approach to force

behavior change among individuals. However, contemporary health
education program underscores an informed decision-making
approach emphasizing community participation and empowerment.
When the idea of primary health care was launched, community
participation was one of the important principles identified for its
implementation. Although everyone talks about it, real community
participation is rarely practiced.
26
What is community?

Community could be defined as organized groups of people who

share a sense of belonging, beliefs, norms, and leadership and who
usually interact within a defined geographical area.
E.g. People living in a Kebele or Woreda
People organized under one religion etc.

The concept of community participation

The health of the community will improve only if the people

themselves become involved in planning, implementing, and having a
say about their own health and health care. Nevertheless,
involvement will not just happen.

Many people emphasize the importance of community participation

for any development issues, including health promotion, to become a
success. However, the question is how serious are we about
involving individuals, families, and communities? Are we prepared -
mentally and professionally to listen to their concerns, to learn from
them what they feel is important, to share with them appropriate
information, to encourage and support them? Are we ready to assist
them in choosing from alternative solutions, in setting their own
targets and evaluating their own efforts? In many cases, so far, the
answer is NO.

27
In health education, we are concerned about how people actually
feel, not how we think they should feel. We are interested in how
people look at their own problems, not only in the problems we see
ourselves. We want people to develop the confidence and skills to
help themselves.

The traditional approach in planning health care or health education

program involves the decision to be made by experts. This approach
is sometimes called the top-down approach and contrasted with the
bottom-up approach where members of the community make the
decisions. In this model people are just told what to do. We make
decisions and expect them to follow.

The concept of community participation or involvement encompasses

the process by which individuals and families assume responsibility
for the community and develop the capacity to contribute to their
health and the communitys development. It is a means by which the
emphasis is on strengthening the capacity of communities to
determine their own needs and take appropriate action. Communities
should not be passive recipients of services.

The following are examples of actions that does not indicate genuine
participation
Involvement of individuals from the community in responding to
health assessment survey questionnaires,

28
 Requesting the community members to contribute labor to dig a
latrine for the school in its village,
Holding a meeting to ask peoples opinions on the issue of
uncontrolled population growth,
Requesting mothers to bring their children to a clinic for
vaccination

We may say communities are participating when they are actively

involved in:

The assessment of the situation/needs

Problem identification
Priority setting and making decisions
Sharing responsibility in the planning, implementing, monitoring
and evaluation
The role of experts should be limited to helping them identify their
problems and to point out methods for dealing with the problems.

Checklist for identifying the degree of participation in a

program:

Is the community involved in planning, management, control and

evaluation of the health program at community level?
Were the felt needs of the community well entertained in the
planning?
29
 Is there a mechanism for dialogue between health system
personnel and community leaders?
Are community representatives nominated in decision-making at
higher levels?
Is there any evidence of the external agents changing their plans
as a result of criticism from the community?
Are deprived groups, such as poor, landless, unemployed, and
women, adequately represented in the decision making process?
Are local resources such as labour, buildings, money etc
exhaustively used?

Benefits of community participation

It leads development endeavors to success.

Shifts the emphasis from the individual to the community e.g. If all
members of a community are convinced of the benefits of
cleanliness, they will help each other to find pure water sources
and keep such sources clean. They will build and use latrines
everywhere in the community and keep them clean as well.
As communities often have detailed knowledge about their
surroundings, their participation makes programs relevant to local
situation.
Ensures community motivation and support. If the community is
involved in choosing priorities and deciding on plans it is much
more likely to become involved in program implementation and
30
 take up of the services because they are seen to be meeting their
needs.
Promotes self-help and self-reliance. If community members do
their own development work, they learn and become more
conscious of their needs and potentials for solving their own
problems, they make use of local skills, they learn to be
responsible for projects and their maintenance, and they gain the
necessary self-confidence to tackle further and perhaps more
complicated development projects.
Improves trust and partnership between the community and
health workers.
Enhances the implementation of the health extension package
program.

Helping people to organize: The Role of Health Extension

Workers

Success in community participation involves a series of overlapping

stages.
They include:
Knowing the community
Learning about the community (its structure and pattern)
Contacting with families, leaders and community groups.
Discussing on concerns and felt needs.

31
 Taking some actions:
Actions on achievable, short-term aims based on felt
needs which bring the community together and build
confidence.
Further activities and organization building
Build up-on existing community organization or
associations.
Formation of committee e.g. Health committee
Educational in-puts
Select and train volunteers
Decision making on priorities
Further actions by the community themselves

In the process of promotion of community participation, community

leaders are very essential.

Who are the leaders?

A leader is a person whose ideas or actions influence others to get

things done that the people want done.
Could be a person of wisdom and sound judgment
Might be one whose advice has been valuable in the past.
Might be wealthy and powerful
Is known to be religious

32
Why are leaders important?

Usually make decisions that result in success or failure of a

project
They are trusted and the community members are ready to
work with them.
Help people in the community know you and gain confidence
in you.
Serve as an officer in an organization or chairperson of a
committee.

In summary, the most important resources for the promotion of health

are the people themselves. Through community participation, you can
use that resource to improve the health of the people. However,
successful community participation is not as simple as people may
think. It requires a demanding task of working with the local
communities, holding dialogue, initial teaching and awarenessraising
activities, supporting community organization, and being able to
convince and work with community leaders. However, overcoming all
the challenges and achieving community participation require
systematic and careful planning. Obviously, this is the usual
challenge for the community health educators.

33
Exercise

1. From your own local experience, describe how the kebele

heath committee functions and the role they have ever played
in the improvement of the health of their people.
2. Out line, the procedures you may follow to mobilize the local
community for the development of spring in their village.
3. List down the perceived advantages of involving the
community in every health education programs.

34
 UNIT FOUR
Health Communication

Objectives

At the end of this chapter, the trainees will be able to:

Define communication
Discuss the components of communication
Explore methods of communication
Explain stages of communication
Identify barriers to effective communication and how to overcome
them

Introduction

Communication is the core of health education and promotion

programs. In human society communication can play an important
part in daily life. We have the advantage of language, spoken words,
songs, and written scripts and so on. It is by communication that an
individual makes himself/herself to understood by others. This act
requires an appropriate design so as transmit an effective message.

35
What is communication?

Communication is the process of sharing of ideas, information,

knowledge, and experience among people to take action.
Communication may take place between one person and another,
between an individual and a group or between two groups.
Communication facilitates creation of awareness, acceptance and
action at individual, group and inter-group level. The process always
involves a sender and a receiver regardless of the number of people
concerned.

Why communication?

To have dialogue with communities.

Influence decision makers to adopt health promoting policies and
laws.
Raise awareness among decision makers on issues regarding
poverty, human rights, equity, environmental issues, etc...
Ensure that the public gives support to government health
promoting activities.
Communicate new laws and policies to the public
Raise public awareness in order to mobilize community
participation.
Develop community action on health issues.

36
Types of Communication

1. One-way communication

This is a linear type of communication in which information flows from

the source to the receiver. There is no input (feed back) from the
receiver. It is commonly used in advertising; the message is designed
to persuade the receiver to take action prescribed by the sender. The
model is best used by organizations when the message is simple and
needs to be communicated quickly, for example, the date and time of
a public meeting. There is no opportunity to clear up
misunderstanding and meaning is controlled by the receiver.

Sender message Channel Receiver

Fig.4.1. One way communication

2. Two-way communication

As the message is more complex, two-way communication becomes

essential. In this type of communication, information flows from the
source to the receiver and back from the receiver to the source. The
addition of feedback allows the sender to find out how the message is
being received and so it can be monitored and adapted to better suit
the receivers needs.

37
 FFeeeeddbbaacckk

SSeennddeerr M
Meessssaaggee C
Chhaannnneell R
Reecceeiivveerr

Fig. 4.2 Complete Communication Model

Two way communication

Components of communication

1) Source (sender)
Originator of message
Can be from an individual or groups, an institution or organization.
People are exposed to communication from different source but
most likely to accept a communication from a person or
organization that they trust i.e. has high source credibility.
Depending on the community, trust and source credibility may
come from:
Personal qualities or actions e.g. a health worker who
always comes out to help people at night.
Qualification and training
A persons natural position in the family or community,
e.g. village chief or elder.
The extent to which the source shares characteristics
such as culture, education, experiences with the

38
 receiver. A person from a similar background to the
community is more likely to share the same language,
ideas and motivations and thus be a more effective
communicator. One of the main reasons for
communication failure is when the source comes from
a different background from the receiver and uses
inappropriate message content and appeals. This
principlethat people who share similar backgrounds
communicate better with each otherhas important
implications for health education. It explains why health
workers who are strangers to the local community are
not always effective in their health education work.
Because of this, the health extension package program
emphasizes recruitment of health extension workers
from the local community. This is particularly relevant
in our country where there is a huge diversified culture.

2) Message

It consists of what is actually communicated including the actual

appeals, words, and pictures and sounds that you use to get the
ideas across.
A message will only be effective if the advice presented is relevant,
appropriate, and acceptable and put across in an understandable
way.

39
A message is said to be good if it:
Is Epidemiologically correct (evidence based)
Is affordable (feasible)
Requires minimum time/effort
Is realistic
Is culturally acceptable
Meets a felt need
Is easy to understand

3) Channel

A Channel is a physical means by which message travels from a

source to a receiver. The commonest types of channels are verbal,
visual, printed materials or combined audio visual and printed
materials. Your choice of channel will depend on what you are trying
to achieve, the nature of your audience and what resources are at
your disposal.

4) Receiver (Audience)

The person or a group for whom the communication is

intended
The first step in planning any communication is to consider the
intended audience.
40
 Before communication, the following characteristics of
audiences should be analyzed.
Educational factors: can they read? What type of
appeals might convince them?
Sociocultural factors: What do they already believe
and feel about the topic of communication?
Patterns of communication: how people show
respect when talking to another person? What time
of the day and which programs do they listen? Which
places do they pass that might be good places to put
up posters?

5) Effect and feedback

Effect is the change in receivers knowledge, attitude and practice

or behavior.
Feedback is the mechanism of assessing what has happened on
the receiver after communication has occurred.

Communication stages

In health education and health promotion we communicate for a

special purpose to promote improvements in health through the
modification of the human, social and political factors that influence

41
behaviors. To achieve these objectives, a successful communication
must past through several stages:

SENDER RECEIVER

Reaches senses

Gain attention

Message understood

Acceptance /change

Behavior change

Change in health

Fig. 4.2 Communication Stages

42
Stage 1: Reaching the intended audience

Communication cannot be effective unless it is seen or heard by its

intended audience. A common cause of failure is preaching to the
converted.
E.g. Posters placed at the health post or talks given at the antenatal
clinics. These only reach the people who attend the services and are
already motivated. But the groups you are trying to reach may not
attend clinics, nor have radios or newspapers. Communications
should be directed where people are going to see them or hear them.
This requires studying your intended audience to find out where they
might see posters, what their listening and reading habits are.

Stage 2: Attracting the audiences attention

Any communication must attract attention so that people will make

the effort to listen/read it. At any one time we receive a wide range of
information from each of our five senses touch, smell, vision,
hearing and taste. It is impossible to concentrate on all these at the
same time. Attention is the process by which a person selects part of
this complex mixture to focus on (i.e. to pay attention to) while
ignoring others for the time being.
Examples of communication failures at this stage are:
Walking past the poster without bothering to look at it,

43
 Not paying attention to the health talk or demonstration at the
clinic,
Turning off the radio program or switching over.

Factors that make communications attract attention

1. Physical characteristics
Size e.g. size of the whole poster
Intensity bold reading in a sentence
High pitched sounds e.g. police sirens
Color-primary colors such as red and yellow
Pictures-photographs and drawing

2. Motivational characteristics
Novelty - an unusual features, unfamiliar and surprising
objects
Interest - felt needs of audience
Entertainment and humor
In general for successful communication, a health extension worker
should:
Consider the design of the poster, including colour, size,
lettering and use of pictures which increase the likelihood of
gaining attention and being noticed.

44
 Deal with subjects that the target group wants to know
something about i.e. which fit with their felt needs and
interests.
Arouse interest by including something unusual in the
communication.
Explore ways of making educational works interesting and fun.

Stage 3: Understanding the message (perception)

Once a person pays attention he/she then tries to understand it. It is a

highly subjective process i.e. two people may hear the same radio
programme and interpret the message quite differently from each
other and from the meaning intended by the sender.
Misunderstandings can easily take place when complex language,
unfamiliar technical words are used and when too much information is
presented.

Stage 4: Promoting change (acceptance)

A communication should not only be received and understood; it

should be believed and accepted. It is easier to change beliefs when
they have been acquired only recently and when its effects can be
easily demonstrated.

45
Stage 5: Producing a change in behavior

A communication may result in a change in beliefs and attitudes but

still may not influence behavior. This can happen when the
communication has not been targeted at the belief that has the most
influence on the persons attitude to the behavior, pressure from other
people in the family or community and lack of enabling factors.

Stage 6: Improvement in health

Improvements in health will only take place if the behaviors have

been carefully selected so that they really do influence health. If your
messages are based on outdated and incorrect ideas, people could
follow your advice but their health would not improve need accurate
advice.

46
Table 4.1 Examples of failure at different communication stages

Stages Immunization poster How to ensure success

1. Reaches senses; Poster is placed at the health center Research target group to find
is seen or heard and only seen by mothers who have out where they go and may see
immunized their children the poster.
2. Gains attention; The poster is lacking striking features Find out interests of target group
holds interest, and doesnt stand out compared with and make it interesting,
noticed attractive commercial advertisements attractive and unusual.
Test it out
3. Is understood; Poster showing large hypodermic Make it simple; avoid confusing
correctly interpreted. syringe held by smiling doctor was words and pictures. Pretest
thought by the community to be a words and pictures with sample
devil with a knife. of target group.
47
4. Is accepted, People believe that measles is caused Base message on what people
believed, learning by witchcraft and do not believe the already believe. Pretest
takes place poster even though they understand messages for acceptability.
the message.
5. Changes in The mother accepted the message Target the influential people and
behavior and wished to take the child for ensure enabling factors are
immunization but the grand mother available. Pretest for feasibility.
didnt allow it.
6. Improves health The vaccine was destroyed by a Choose most important
break in the cold chain and the child behaviors. Make sure support
became sick with measles. services are functioning.

48
Common communication approaches

Informing - The new idea is introduced and made familiar to the

target audience.

Educating - The new idea is explained including its strengths and

weaknesses.

Persuading- The audience is given convincing argument that

motivates them to take an action or accept a new
idea.

Entertaining - The attention of the audience is drawn to the new

idea by stimulating the audiences emotions

Methods of Communication
1. Intra - Personal communication
2. Inter - Personal communication
2. Mass communication

Intra-Personal communication

It takes place inside a person. It includes the beliefs, feelings,

thoughts and justification we make for our actions. E.g. a person may
look at an object and develop a certain understanding. However, this

49
could be affected by a number of factors including previous
experience, language, culture, personal needs, etc.

Interpersonal Communication

It means interaction between two or more people who are together at

the same time and place. E.g. between health extension worker and
community member, a teacher and students in a class. The decisive
criterion for personal communication is that communication happens
at the same time and place.

Advantages
Two way communication
The communication could utilize multi-channels (both verbal
and non verbal) i.e. far more channels are involved than is
possible in mass communication.
Useful when the topic is a taboo or sensitive.

Limitations
Requires language ability of the source.
Requires personal status.
Needs professional knowledge and preparation.

50
Mass communication

It is a means of transmitting messages to a large audience that

usually reaches a large segment of the population. It uses mass
media. Mass media includes broadcast media (radio and television)
as well as print media (newspapers, books, leaflets and posters)

Advantage:
Reach many people quickly
They are believable specially when the source is a credible one

Limitation:
One sided (linear)
Doesnt differentiate the target

Barriers to Effective Communication

A breakdown can occur at any point in the communication process.

Barriers (obstacles) can inhibit communication, resulting in
misunderstanding, lack of response or motivation and distortion of the
message. This can lead to conflicting of views, insecurity and the
inability to make effective decisions. Barriers can also prevent the
achievement of project or program goals if we are not aware of them
or not prepared for them.

51
Common barriers to effective communication

Competition for attention (noise)

Language difference and vocabulary use
Age difference
Attitudes and Beliefs

We cannot avoid or overcome all these barriers but we have to find

ways of minimizing them.

52
Competition for attention (noise)

Noise is a major distraction during communication. It could be:

Physical noise avoidable
Internal noise - any physiological or psychological state that
could undermine a persons ability to communicate effectively
such as being ill or beset by personal problems. We may or
may not be able to do anything to help in this kind of situation.

Language difference and vocabulary use

This includes whether there is language difference, vocabulary use,

different meaning of the same word or sentence.

Age difference

Age difference between the sender and receiver is a barrier to

effective communication. For example, if the sender is young,
inexperienced and not knowledgeable the audience may not give
proper attention resulting in a communication barrier.

Attitudes and Beliefs

The community may be misguided by expectation on the role of

health extension workers. They either think that health extension

53
workers are supposed to do every thing for them or that they know
too much or do not require services,
Cultural beliefs of a people influence the rate at which they accept
and adopt new ideas and skills. Normally the beliefs of a community
may dictate what foods should be given to children and also their
related taboos. In such circumstances it will be very difficult for a
health worker to convince the mothers to feed their children on certain
food despite their nutritional values. For this reason it is necessary for
the health extension workers to be aware of the attitudes and beliefs
of the communities they are working with.

How to overcome barriers of communication

The sender must know his/her audiences:

Background
Age and sex
Social status
Education
Job/work
Interests/problems/needs
Language
The messages must be:
Timely
Meaningful/relevant
Applicable to the situation
54
 The audience must remove their own barriers. Members of the
audience could be:
The non-listener type who refuse to listen.
The know-it-all type who thinks he/she knows the
answer to everything.
The impatient type who is reluctant to sit and jumps to
conclusion.
The negative personality who enjoys saying no to
everyone.

Even if all the barriers have been removed, communication could

still be a failure without good presentation. Good presentation
requires complete understanding of the subject establishing good
relationship with the audience, choosing the right channels or
media, proper utilization of the chosen media and using the
multimedia approach.

Characteristics of effective communication

All barriers have been removed.

The proper media has been chosen.
A good presentation has been made.
Two way communication has been established.

55
Exercise

1. Discuss the difference between one-way communication and

two-way communications.
2. Discuss the possible causes of failure for a radio program
given on nutrition.
3. Identify the possible barriers in your locality that you think
could affect effective communication in the process of
promotion of family planning services.

56
 UNIT FIVE
Educational Methods And Materials

Objectives

At the end of this chapter, the trainees are expected to:

Explain the common methods of transmitting health
information
Describe the advantages and disadvantages of interpersonal
and mass media communication means
Explores the role of counseling at the grass root level
List major traditional as well as modern methods for group
communications
Explain common teaching aids used for effective
communication

Introduction

Basically health education helps people to make wise choices about

their health and the quality of life of their community. To do this,
accurate information must be presented in an understandable way
using different methods.

57
Ways to put across health messages:

1. Direct Interpersonal (Individual and groups)

2. Indirect Mass media and visual aids.
To transmit information effectively, you have to choose appropriate
educational tools. For example, where resistance is anticipated
because the changes recommended are contrary to deeply held
traditions, intensive interpersonal educational efforts may be
necessary. Where the benefits of a recommended change are so
great that resistance is low, mass media can be used.

The important thing to remember is that effective health

communication is seldom achieved through the use of one method
alone. Nearly always, a combination of techniques is needed to
achieve behavior changes. Both effectiveness and costs must be
considered in choosing a combination of techniques. Besides,
selection of local media is appreciably useful.

I. Educational methods

1. Individual educational methods - Counseling

Counseling is one of the approaches most frequently used in health

education to help individuals and families. It is a person-to-person
communication in which one person is helped by another to increase

58
in understanding, ability and confidence to find solutions to own
problems.

This service could be given to patients at the health center, to pupils

at school, to families during a home visit or during casual visits to
community (e.g. Market place, at water well etc).

Home Visits

Advantages
When people are in their home, they usually feel happier and
more secure. You may find that people are more willing to talk in
their own homes than when they are at the clinic.
It also gives an opportunity to see how the environment and the
family situation might affect a persons behavior; thus, making
observations and any necessary suggestions for change right
there.
Keeps a good relationship with people and families
Encourages the prevention of common diseases.
Enables detecting and improving troublesome situations early,
before they become big problems.
Enhances checking on the progress of a sick person, or on
progress towards solving other problems.
Motivate the family on how to help a sick person in which their
participation is needed.

59
 Therefore, health extension workers should visit all homes in their
communities regularly. Home visits become convenient if we
design our own family health education folder for use.

What information should be in the folder and kept up to date?

The family name.
The address and location of the house
The date of the visit.
The name and ages of all members of the house hold. (Be
sensitive to local customs about collecting such information)
Health problems
Information discussed
Ideas offered
Agreements reached
What you agreed to do
Date of next visit

Purposes of counseling

To help individuals increase knowledge of self

To encourage individuals or families to think about their problems
and understand the causes.
Help people commit themselves to take action on their own will to
solve the problems.
Help individuals to choose, but not forcing them to do so.
60
Principles in counseling

Counseling requires establishing good relationship between the

counselor and the client
Counselors should assist people identify their own problems.
Counselors develop empathy (understanding and acceptance) for
persons feelings. It is thinking by putting self on the shoe of the
others.
Counselors should never try to persuade people to accept their
advice. Rather help people to think about all the factors involved
in their problems and encourage them to choose the solutions that
are best in their particular situation.
Counselors should always respect the privacy of the people they
are helping. They never reveal information without specific
permission.
Counselors should share information and ideas on resources,
which the client needs in order to make a sound decision. For
example, many people do not realize the connection between
their behavior and their health.

61
Below is an example of the problems that arise when a
person is advised and forced:

During a home visit one health extension worker (HEW) saw a

mother with a marasmic child. The child was so thin and very
small for age.

The HEW worried the child would die in a near future. She
scolded the mother for not taking to the clinic. The HEW
persuaded the mother to take the child to a hospital where
nutrition rehabilitation is given and stay there until the child would
regain weight.
The mother nodded her head in agreement. While she was
packing her things she began to cry.

A brother of the womens husband came to see what she was

crying about. The HEW explained, but the man become angry.
He said there were many good reasons why the woman was
crying. She was worried because, if she stayed in hospital, there
would be no one to care for her other two older children. She had
recently moved to another village with her husband. She felt that
there would be no one whom her children knew and trusted
enough to stay with.

62
 Also the mother was crying for fear that the HEW might refuse to
help her in the future, if she did not agree to go to hospital now.

This health worker had obviously not learned the techniques of

counseling; otherwise, she would have followed the simple rules
listed above.

2. Group Educational Methods

It is needless to mention that much of the problem solving in the
community has to be done by group work and cannot be attempted at
individual level alone. Specifically, working with groups is a major
activity in health education. When people get together to identify,
define, and solve a problem, they have many more resources than
when they work individually.

What is a Group?

A group could be defined as a gathering of two or more people who

have a common interest.
Example of groups often found in a community:
A family
A health committee
People working at the same factory, business, or agency
A class of school children
A farmers cooperative

63
 A youth club
People attending a religious ceremony together
Some friends getting together to relax
A gathering of patients at a clinic
People riding together on a bus

Types of Groups - There are two main kinds of group

1. Formal groups
Groups that are well organized with some rules and
regulations
E.g. Farmers cooperative, Womens Associations

2. Informal groups
Groups that are not well organized
E.g. People attending market on a particular day
People attending funereal ceremony

Characteristics of formal group

Has a purpose or goal that everyone strives to achieve together.

There is a set membership, so people know who is a member and
who is not.
There are recognized leaders who have the responsibility of
guiding the group to wards achievement of its goals.

64
 There are organized activities such as regular meetings and
project.
The group has rules that members agree to follow and works
towards the welfare of the members.

Characteristics of informal gatherings

May have some features in common, but no special goal that they
are trying to achieve together E.g. People riding together on a bus
No special membership or feeling of belonging
People come and go at will
No special leader selected, no special rules apply
Usually no special activity is planned by the people themselves
E.g. People coming to watch a football match
There is usually more concern for self, and less for the welfare of
the other people.

Group Dynamics

Group dynamics is a field of study concerned with scientific methods

to determine why groups behave the way they do. Group dynamics is
of immediate importance to the health educator (including HEWs)
who is interested in helping groups to get together, discuss, take
decisions and implement their programs to solve the problems. In a
positive dynamism, it is necessary that the commonness of purpose,
65
a sense of belonging and an attitude of selflessness be developed
amongst the individuals. Otherwise it will be difficult for the group to
stay as a cohesive unity and turn out useful work or achieve its
objectives.

Some of the important qualities and behavior patterns for a group to

function harmoniously and effectively are listed below.

They have to be group conscious. In other words, they should

understand that they are an integral part of a group with
certain objectives.
There should be a sense of shared purpose /goal.
A spirit of interdependence and helpfulness and selflessness
is very essential
There should be frankness and sincerity of opinion and
purpose
There should be a sense of freedom among the members to
discuss matters without any fear or complex
Responding politely to the suggestions of others
Attending meetings regularly and on time.
Thanking each other for suggestions given.

66
The Value of Group Education

In a group, one can find the support and encouragement needed

to promote and maintain healthy practices.
It permits sharing of experience and skills.
Working in groups makes it possible to pool the resources of all
members.
E.g. to dig a well, group of families can contribute enough money

Common Methods Used for Group Education

a) Group discussions

Health education has been quick to recognize that groups provide an

ideal set-up for learning in a way that leads to change and action.
Discussion in a group allows people to say what is in their minds.
They can talk about their problems, share ideas, support and
encourage each other to solve problems and change their behavior.

Size of a group

For sharing of ideas an ideal group is the one with 5-10 members. If
the members are large every one may not have a chance to speak.

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Planning a discussion

Planning a discussion involves:

Identification of the discussants that do have a common interest
E.g. mothers whose child suffers from diarrhea.
Getting a group together
Identification of a comfortable place and time:

Conducting the discussion

Introduction of group members to each other

Allow group discussion to begin with general knowledge
E.g. any health problems they have ever faced
Encourage everyone to participate.
- Have a group act out some activity (drama, role play)
- Have a villager report on a successful experience
- Limit those who talk repeatedly and encourage the quiet to
contribute.
Limit the duration of discussion to the shortest possible, usually 1-
2 hrs.
Check for satisfaction before concluding the session.
E.g. Do they think that they are learning?
Do they think the group should continue?

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b) Meetings

Meetings are good for teaching something of importance to a large

group of people. They are held to gather information, share ideas,
take decisions, and make plans to solve problems. Meetings are
different from group discussions. A group discussion is free and
informal, while meetings are more organized. Meetings are an
important part of successful self-help projects.

Planning a meeting

It should be need based

Determine the time and place
Announce the meeting through village criers or word of mouth.
Prepare relevant and limited number of agendas.

Conducting the meeting

Should be led by a leader

Encourage participation as much as possible
Try to reach at consensus based decisions
Use some visual aids to clarify things
Finally, get ready to take actions to solve problems.

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c) Clubs

There are many kinds of organizations to which women, men and

young people belong. Clubs are becoming popular in many areas.
They provide an opportunity for a systematic way of teaching over an
extended period of time. E.g. a group of citizens could form an
association to deal with problems related to a major local disease or
to protect the environment.

d) Demonstrations

A demonstration is a step-by step procedure that is performed before

a group. They involve a mixture of theoretical teaching and of
practical work, which makes them lively. It is used to show how to do
something. The main purpose of demonstrations is helping people
learn new skills. The size of the group should be small to let members
get the chance to practice. It is particularly useful when combined
with a home visit. This allows people to work with familiar materials
available in the locality.

Planning the Demonstration

Identify the needs of the group to learn

Collect the necessary materials such as models and real objects
or posters and photographs.

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 Make sure that it fits with the local culture. E.g. for nutrition
demonstration you have to use the common food items and local
cooking methods.
Prepare adequate space so that everyone could see and practice
the skill.
Choose the time that is convenient for everyone.

Procedures

Introduction: Explain the ideas and skills that you will

demonstrate and the need for it
Do the demonstrations: Do one step at a time, slowly. Make
sure everyone can see what you are doing. Give explanations
as you go along.
Questions: Encourage discussion either during or at the end
of the demonstration. Ask them to demonstrate back to you or
to explain the steps.
Summarize: Review the important steps and key points
briefly.

Checklist to evaluate a demonstration

Did the audience learn how to do what was demonstrated?

What evidence was given that the audience plans to carry out this
practice on their own?
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 Visit members of the audience to see if they are using the new
methods demonstrated.
How could your demonstration be improved?

e) Village criers

They spread information in the community in the past eras & even
today in remote areas where modern mass media are scarce. When
they have some thing to say, ordered by village leaders, they may
use a bell or drum to attract attention. Drum beats and other sounds
can be a special code or signal that people understand. The
significance about these people is that the villagers know who is the
real village crier and may only respect information coming from him or
her.
The following messages could be passed on:

A reminder to mothers to immunize their children

A request that people participate in a village sanitation campaign
A call for people to work in a community project such as digging a
well
A warning about dirty water during cholera outbreak

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f) Songs

People sing to express ideas and feelings, such as love and sadness,
to tell story of a famous person, commemorate religious days etc.
Particularly village people like to sing and dance and almost every
village have someone who can sing and put works to music. In
addition to expression of feelings, songs can also be used to give
ideas about health. You can give topics that you want to make
popular to those persons for synthesis and dissemination. For
instance, the following issues could be entertained:

The village with out safe water

The malnourished child who got well with the proper food to eat
The village girl who went to school to become a health extension
worker
The house where no flies and mosquitoes breed

g) Stories

Stories often tell about the deeds of famous heroes or of people who
lived in the village long ago. Story telling is highly effective, can be
developed in any situation or culture, and requires no money or
equipment. It should include some strong emotions like sadness,
anger; humor, or happiness as well as some tension and surprise. An
older person, instead of directly criticizing the behavior of youth, may

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tell stories to make his/her points. He/She may start by saying, I
remember some years ago there were young people just about your
age and then continue to describe what these young people did
that caused trouble. Stories may also be a way of re-telling
interesting events that happened in a village. So stories can
entertain, spread news and information so that people are
encouraged to look at their attitudes and values, and to help people
decide how to solve their problems.

h) Proverbs

They are short common-sense sayings that are handed down from
generation to generation. They are like advice on how best to
behave. Some proverbs are straight for ward- others are more
complicated.
Examples
One does not go in search of a cure for ringworm while
leaving leprosy unattended. This is to mean: try to solve the
most serious problem first.
A young man may have as many new clothes, but not as
many worn-out clothes, as an old man. This is to mean: An
old man has more experience than a young one
Prevention is better than cure.

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The first proverb could be useful during a talk to mothers that
emphasizes the importance of bringing their children to the clinic
when they are sick, instead of going about some other business. The
second proverb could encourage young people to respect and care
for their elderly parents.

i) Drama

Drama is less common in villages, but it is a good means to entertain

people in a message. Their preparation, practice and others may
incur time and money. This means that it is somehow difficult to
prepare repeatedly. Yet, they are extremely useful for conferences,
workshops and refresher courses.

Ask members of the community to help write the script (e.g. teachers
or individuals who enjoy and are capable of writing such scripts.) or to
play a drama someone else has played earlier. Dramas should have
one main learning objective but can often include 2 or 3 other less
important objectives as well. Alike stories, dramas make us look at
our own behavior, attitudes, beliefs and values in the light of what we
are told or shown. Plays are interesting because you can both see
and hear them.

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General principles

Keep the script simple and clear

Identify an appropriate site
Say a few words at the beginning of the play to introduce the
subject and give the reasons for the drama
Encourage questions and discussions at the end

j) Role - playing

Role-playing consists of the acting out of real-life situations and

problems. The player tries to behave in a way that the character
might behave when faced with a given situation or problem. It is used
to show different people feel about a problem and what they should
do about it.

Role-playing can be used to start off a discussion, to see what

possible consequences of a certain action are, and to develop a
better understanding of why people feel as they do. We learn about
our own behavior during a role-play, we can discover how our
attitudes and values encourage cooperation and problem solving or,
how our attitude and values create problems.

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II. Teaching materials (aids)

Teaching materials include all materials that are used as teaching

aids to support the communication process and bring desired effect
on the audience. The following are some selected teaching aids that
are commonly used in health education programs.

1. Audios

Audios include anything heard such as spoken-word (talk), music or

any other sounds. Talks are the most commonly used audio teaching
methods.

Characteristics of audios:
- Effective when based on similar or known experience
- Could be distorted or misunderstood when translated
- Easily forgotten

1.1 Health talks

The most natural way of communicating with people is to talk with

them. In health education, this could be done with one person, a
family, or with groups (small or large). Health talks have been, and
remain, the most common way to share health knowledge and facts.
However, we need to make it more than advice and make effective by

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combining it with other methods, especially visual aids, such as
posters, slides, demonstrations, video show etc.
In principle, it should be given to smaller group (5 to 10 people)
though it could be given for larger group like radio talk. In health talks,
unclear points could be asked and discussed.

In preparing a talk, consider the following points:

Know the group: their interests and needs

Select single and simple topic: e.g. Nutrition is too big as
a topic. Thus, select subtopic such as breast-feeding,
weaning diet etc.
Have correct and up-to- date information.
Limit the points to only main once.
Write down what you will say, use examples, proverbs
and stories to help emphasize points.
Make use of visual aids.
Practice your whole talk
Make the talk as short as possible - usually 15-20
minutes talk and 15 minutes discussion.

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2. Visual aids

Visuals are objects that are seen. They are one of the strongest
methods of communicating messages; particularly when
accompanied with interactive methods.

Advantages
They can easily arouse interest
Provide a clear mental picture of the message
Speed up and enhance understanding
Can stimulate active thinking
Create opportunities for active learning
Help memory and provide shared experience.

Visuals are more effective than words alone, and it will be rather more
effective when extended to practice (action).

The Chinese proverb goes for this:

If I hear, I forget
If I see, I remember
If I do, I know

Like wise, it is a common understanding that you remember 20% of

what you hear, 50% of what you hear and see, and 90% of what you
hear, see and do. With repetition close to 100% is remembered.
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2.1. Non-projected materials (aids) or graphics

They are shown or displayed and do not necessarily depend on any

projected equipment.

a. Leaflets

Leaflets are unfolded sheet of printed material. Leaflets can be very

appealing if their message is simple and clear, and if the language is
understood by the reader. In preparing them, short sentences and
paragraphs should be used, illustrated with simple drawings or
pictures that are easily understood. They need to be pre-tested
before distributed to the villagers.

b. Newspapers/Newsletters

Newspapers might be of some help in reaching the villagers. Very

often, though, the national or regional newspapers do not reach
smaller communities, or the people are unable to read them. In this
case, newsletters, written by the villagers themselves, teachers and
extension workers can become the communities newspaper. Place
copies on a bulletin board or wall in a public meeting places (market,
well, bar).

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c. Photographs

Photographs can be used to show people new ideas or new skills

being practiced. They can also be used to support and encourage
new behavior. They are best used with individuals and small groups.
People can compare photos taken of malnourished children in the
village before and after receiving treatment.

Advantages
They can be photographed in the town where you work thus
assuring familiarity and recognition by the people.
They are relatively inexpensive and reproducible for different uses
(posters, flipcharts)
You can make them your self.

d. Posters

A poster is a large sheet of paper, often about 60 cm wide by 90cm

high with words and pictures or symbols that put across a message. It
is widely used by commercial firms for advertising products, but can
also be used for preventive purposes.

Advantages

Give information and advice, e.g. beware of HIV/AIDS!

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 Give directions and instructions, e.g. how to prevent HIV / AIDS
Announce important events and programmers, e.g. World AIDS
day

Standard rules in making posters:

All words should be in the local language
Words should be limited and simple
Symbols that illiterate people will also understand should be used
Mix of colors should be used to attract attention
Only put one idea on a poster.

General principles:

They should contain the name of the event, date, time, and place
They should be large enough to be seen from some distance;
They could be used for small or larger groups
Should be placed where many people are likely to pass
Do not leave them up for more than one month, to avoid boredom
Never use them before pre-testing.

e. Flipchart

A flipchart is made up of a number of posters that are meant to be

shown one after the other. In this way, several steps or aspects of a
central topic can be presented such as about family planning. Their
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purpose is to give information and instructions, or record information
when prepared with blank pieces of paper.

f. Flannel graphs

A flannel graph is a board covered with flannel cloth. The flannel

graph is one of the most effective and easily used teaching aids
because it is cheap and portable. Pictures and words can be placed
on the board to reinforce or illustrate your message. It is very useful
with people who do not read and in groups of less 30 people.

g. Displays

A display is an arrangement of real objects, models, pictures, poster,

and other items, which people can look at and learn from. Like a
poster, it provides ideas and information but where as a poster
contains only one idea, a display has many. E.g. how a child
develops and grows.

2.2. Projected aids

Projected materials are simply educational materials that are shown

to people using a projector. They are used to facilitate lectures or
seminars/trainings. The group should not be more than 30.

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The commonly utilized once are slide projectors (color pictures on a
transparent object), overhead projectors (display written or drawn
materials on a transparency), and power point projectors. They are
expensive, requires expertise and electric power. They are useful to
underline the most important points in a talk or lecture.

Mass Media

It is one way of giving health education. The communication that is

aimed to reach the masses or the people at large is called mass
communication. The media that are generally used for mass
communication go by the name of mass media. The commonly used
mass media are microphones or public address system, radio,
television, cinema, newsprints, posters, exhibitions.
Mass media are the best methods for rapid spread of simple
information and facts to a large population at low cost. However, the
major concerns with this method of communication are availability,
accessibility and popularity in a given community.

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Table 5.1.Main characteristics of mass media and face- to- face channels

Characteristics Mass media Face-to-face

Speed to cover large population Rapid Slow

Accuracy and lack of distortion Highly accurate Easily distorted

Ability to select particular audience Difficult to select audience Can be highly selective

Ability to fit to local needs Provides non-specific information Can fit to local need

Direction One-way Two-way

Feed back Only indirect feedback from surveys Direct feedback possible

Main effect Increase knowledge/awareness Change in attitudes and

behavior; problem solving.

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Selection of Teaching Methods and Materials

The selection of the teaching methods and aids depends on

1. The type of the message
2. The purpose
3. The people addressed
4. Availability of resources
5. Availability of skills.

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Exercise

1. List formal and informal groups found in your community.

2. Mention the advantages and disadvantages of face-to-face
and mass media communication channels.
3. Identify traditional communication methods used in your
locality and describe their strong aspects.

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 UNIT SIX
Training

Objectives

At the end of this chapter, the trainees will be able to:

Describe what training is
Discuss types and phases of training
Explore the methods of training
Discuss evaluation of training process

Introduction

In the previous chapters, we have tried to see some basic principles

and components of communication and teaching methods and
materials. In this chapter, we will see training approaches that are
relevant to health educator roles and activities. In the context of the
professional role of health educator, training is of vital importance.
The health educator has to play the role of trainer for training various
categories of health personnel and other development workers.

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What is Training?

Training is the process of education in which both the mind and body
are brought under exercise and discipline. It is the act of acquiring
necessary qualification or occupation or feat of physical skill or
endurance.

Types of training

Pre-service: involves the preparation in general of any trainee

for qualifying for a certain set of professional or specific job
oriented roles.
Orientation training: refers to a preparation for the specific job
to be performed in a particular position.
In service training: It is a refresher course given with a view of
updating knowledge and skills of the workers in any
department or organization.

Phases of Training

Preparation (pre-training) phase

Training phase
Post-training (follow-up component)

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a. Preparation phase

This phase involves several activities to be carried out.

Conducting training need assessment. This is to ask whether
there is a need gap for a certain kind of health workers to
carry out some work
Identify aims of the training program.
State needs or problems that are expected to be solved
Identification of the trainees. Recruiting and selecting learners
is the single most important step in any training program.
This is because the problems to be solved primarily rests on
their attitude and behavior when they are deployed for
services. Quite often recruitment of community health
workers is effected through political leaders. However, most
of the time this results in failure because it is absolutely
necessary for community members to be able to trust and
have confidence in the people who are responsible for their
health. This is particularly true for traditional birth attendants.
Therefore, the community members must have an important
part in choosing who is going to be trained.
Know who the learners are. Their educational and training
background experiences they have with this problem, topic or
subject, their interests, and their social and cultural
background.

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 Identify resources available- time, equipment, space, trainers
and written materials including books, handouts
Determine the four important areas (domains) of learning
going to be changed (knowledge, belief, attitude and skill)
Determine the teaching methods to be used depending on
the targeted domain of learning.
Arrange living condition of the trainees and facilitators (food,
lodging, transportation, recreation, financial support).
Determine how the learners and the program be evaluated.
This may include pre-test and post test, feedback from the
trainees at the end, follow-up for the graduates.

Choosing Training Methods

Some of the important questions to ask our selves to determine the

type of methods to use are:
What are the learning objectives? Is it to influence or change
thinking, believing, feeling or doing?
Who are the learners? Educational, cultural, motivational, future
role, experience status.
How much time do we have?
What other resources are available?
How can active involvement by the participants be made certain?

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 Based on these curies, the following methods or combinations of
them can be used.
Lecturing- the most common and easiest method but the least
efficient especially in addressing how to do a job.
Lecture and discussion-asking questions encourage
participation. It gives more opportunity to learn.
Provision of textbooks /handouts.
Learner presentations
Demonstrations-essential tools of training in task learning
Audiovisual support- flipcharts, posters, slides, models.
Popular art forms-they are one of the most effective training
methods for many resources. These include dramas, role-
plays, poems, sings, games, puppets

b. Training Phase

In the actual training phase training curriculum is to be followed and

the necessary arrangements has to be made for concurrent
monitoring and evaluation. The training curriculum should be modified
now and then by making mid course correction and change to suit the
objectives and needs. The training phase must insure the
opportunities for learning by doing and also creating necessary
climate or environment in which learning can take place effectively.

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c. Evaluation of Training

Evaluation is a process of determining the degree or amount of

success with pre-determined objective.

Steps for evaluation

Input evaluation- examines what resources were used based

on which we can calculate the cost per graduate-efficiency.
Process evaluation- looks at what methods are used; see
how trainees are progressing, training run as per the
schedule
Output evaluation- reviews the quality and numbers of people
trained to see if they meet standards and the targets or
objectives set during the planning process. This includes the
knowledge and skill tests.
Outcome/Impact evaluation- examines what the results or
effects the graduates have achieved in the work they are
trained for. This is performed using field assessment through
observations and surveys.

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Exercise

1. List down the types and phases of training.

2. What are the steps to follow in the evaluation of
training?

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 UNIT SEVEN
Planning, Implementation And Evaluation Of
Health Education Programs

Objectives

At the end of this chapter, the trainees are expected to:

Discuss on the planning process
Describe how to carry out and evaluate health education
programs

Introduction

So far, we have gone through important points related to knowing

how human behavior influences health, relevance of participation of
beneficiaries in every steps of health education programs,
communication channels and teaching methods and materials.

A. The planning Process

Planning a health education program is like planning a journey. In

planning a journey, you know where you are and have to decide
where to go. Then you must decide the best way of getting to your
destination. If you do not arrive at the place you wanted to go, you

95
 realize that you are lost. Likewise, the starting point for health
education program is the present health situation, e.g. level of
immunization, family Planning coverage, malnutrition status, or
sanitation, that you would like to improve to a better level, which is
your destination. To do this, you must decide on a strategy - the
methods you must use to improve the situation. At the end, you
evaluate your program to find out if you have reached your target - or
have got lost!

Selecting
appropriate
Assess resource methods
Develop
Set Objectives indicators

Prioritize Carry out the

project
Define problems

Evaluate
Information
gathering Re-
plan

Fig. 6.1 Project Planning Cycle

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Steps in Planning

1. Information gathering

A good way of finding out the present situation is to carry out a

community profile or diagnosis. Following are some types of
information, which may be helpful in understanding the community
and its health problems.

1.1. The community and its general physical characteristics

Efforts in health education must be based on a clear understanding of

the community and its problems. These include:
The size of the community
The kind of crops, food, natural resources existing
The transportation routes
Localization of existing schools, religious institutions, market
places, recreational facilities, health facilities and other
public and private services.

1.2. Information on the number of people and their characteristics -

may be from available records.

Number of people who live in the area

Their sex and age group
Average size of a household
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 Average number of pregnancies, children alive, and children
died in the last one year.
Literacy status of the adults

1.2. Community groups and their impact on the health care system

Learn the existence of various social groups and the nature of

relationships both within and between those groups. E.g. Ethnic
class, religious groups etc.

1.3. The communication network

To reach the people in the community, it is necessary for you to know

how information and rumors spread within the community.
What the formal and informal channels are
Who the participants in those channels are
Who the communicators are and how effective they are
Learn how various leaders communicate their ideas and
opinions and note to what extent their messages are accepted.
A good way to gather this information is to observe where people
gather and listen to the types of information that is spread. You can
also attend meetings, festivals, and religious gatherings. You can
spend time socializing with women in the market or at village wells, or
you can ask people to whom they would go for advice on health

98
matters and to whom they feel comfortable giving advice or
forwarding news.

1.5. The family structure

As we look about a society, we encounters good many differences in

the ways in which families are organized. Families vary in their
composition and in their descent, residence and authority patterns
An understanding of the family structure, the status of various
members of the family and who is involved in the decision-making
process within the family on all major decisions as well as those
related to health is valuable to work with community.
Without this knowledge, you may direct your educational activities
toward the wrong member of the family.

1.6. The political structure in the community

Explore the basis for leadership and power within the community.

1.7. The economy and its impact on health

Know about businesses, industries, agricultural conditions,

unemployment, family debts, and how the land is distributed. This
information will increase your knowledge of what is important to
the people and what resources are available to them.

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1.8. Religion and its impact on health

Religion may have a great influence on the lifestyle of the community

including the health practices and beliefs of individuals. A mother may
believe that her child is sick because it is GODS desire. It is
important, therefore, to know:
Who the major religious groups in the community, their leaders &
their roles in the community life
Whether there is any conflict between them
The attitude of the government and the community to wards
religious affiliated programs.

1.9. Health beliefs and practices

How people define good health and disease

Some people may believe that prevention of illness is impossible,
or very difficult
Others may value only a particular method.
What methods are used to help maintain their health?
What are peoples attitudes towards such services as
vaccinations, Family Planning, insecticide spray etc.
What are local attitudes and practices regarding personal
hygiene?
Are there special beliefs concerning food? When child is ill, for
pregnant ladies etc.

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 Breast feeding and weaning practice for infants
Where do most women give birth? Who assists in delivery?
What methods are used to cut the umbilical cord?
Are mothers confined in darkroom after delivery?
Sources of water, excreta disposal, do they know that certain
diseases may be contracted through human feces?

All the above information could be gathered using formal and informal
ways of obtaining information. Informal ways include, observing and
talking to people, and reading reports, official documents and
newspapers. Common example for formal method is conducting
surveys using structured questionnaires.

2. Defining and prioritizing problems

The first requirement in bringing about change is to agree that there is

a problem and that something should be done about it. Defining of
specific health problems must involve the community members. Ask
questions in an attempt to find out how they view the health
situations. Start from the general and work down to the specific
problems you have in mind. For example, if you found a very
unsanitary environment in your survey of the community you might
contact the leaders and proceed as follows:
What needs to be done in this village to improve their life?
What are the illnesses most common in this village?

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 What is the extent of the problem? How bad is the situation?
What do people die of? Which groups or individuals are most
affected?
Do they have diarrhea, febrile illnesses, or worms in this village?
What causes these illnesses?
Are there any latrines in the village? What do people use?
Has any thought been given to building latrines?
Why some people refuse to use them?
Do people in the village plan together to get rid of these
problems?

At times, your priority problem may not coincide with the felt need of
the community. For example, your own analysis may indicate that
improved sanitation is most needed but the community may feel that
they should first improve their road so that they can market what their
produce. In such cases, you cannot neglect the need of the
community if you anticipate good community participation and
establish sustainable project. In the above case you need to talk to
the concerned offices and community leaders and convince that
helping to meet the communitys goals will make it easier for them to
try to improve their environment. Perhaps the community will agree to
get aside money generated from their marketing for sanitation.

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Generally, whenever people come up with multiple needs, the
following four questions can help them see their problems more
clearly and make their choice of priorities easier.
Which is the most serious problem?
E.g. Lack of food to eat by a family.
Where does the greatest future benefit lie?
E.g. skills training for unemployed.
What needs can be met with the resource available? E.g.
purchasing inexpensive, yet nutritious foods available at the local
market.
Which are the problems of greatest concern to the people?
E.g. A health post compared to a school.

3. Setting goals and Objectives

For a program to succeed, we must know clearly what we want to do

and how we are going to do it. After people have decided upon their
priority needs, they must spell out exactly what they want, i.e. their
objectives.

An Objective is a statement of proposed change over a fixed time

period. It should be measurable, relevant and possible to achieve. It
has to describe:

What you want to change?

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 How much change you want?
For whom or for what you want the change?
When? By what time or date?
Types of objectives in health education

1. Health Objectives

If measles is a serious problem in a community, a primary health care

program to solve the problem might have the following as its health
objective.
Fewer children will get measles
Those who do get measles will recover quickly and suffer no
disabilities
No children will die from measles.

2. Educational Objectives

Since peoples behavior affects their health, there will be certain

actions that people must carry out to solve their health problems.
Such are educational objectives of a program. Some examples of
educational objectives for a program against measles include:
Mothers will bring their children for immunization
Mothers whose children get measles will bring them quickly to the
health worker for care.

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 Children who get measles will be fed as well as possible to help
them recover more quickly.

4. Identifying and Obtaining Resources

4.1. Resources inside the community

It is best to find resources inside your community for two reasons: For
one thing, it saves money. More importantly, people are proud to be
able to help themselves, which in turn encourage people to try to
solve more problems by their own efforts. Some of them include:
Places to hold meetings, discussions, and trainings, such as
schools, and halls
Some people may be able to donate money to buy materials.
Some have skills to contribute, e.g. carpenters, teachers, masons,
artists, traditional healers, weavers and potters
Many can provide labour.
Some may support transport: bicycle, motor cycle or vehicle

4.2. Resources outside the community

If resources within are not adequate one may seek from outside:
Some agencies and ministries can donate funds
People with special skills, such as finding under ground water for
wells, may come from outside.
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 Educational materials such as films and posters could be given
from outside agencies.

Health education Resources

Local Media

One should be able to identify local and traditional means of

communication such as proverbs, stories, and fables, which elders
use to pass traditional values on to the young.
Local leaders may use village criers or bell-ringers to announce
upcoming events.
Traditional songs or plays may communicate important ideas and
values.
Local artists, printers, and photographers can be involved in
designing, and producing educational materials.

Outside sources

These may include mass media such as newspapers and radio.

Ministries of health and information could supply or loan films,
posters, and vans with loudspeakers.
A local school teacher who is a subscriber of newspaper can use
to teach pupils and inform parents.

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5. Selecting appropriate Methods

It is not enough to decide what will be done, by whom and when, we

also need to decide how it will be done.

Once a health worker understands the reason behind behavior that is

causing a health problem, he or she can use many different methods
to encourage a change in that behavior. Generally, there are some
basic issues to consider before choosing health education methods:
How fast do people change?
How many people are involved?
Is the method appropriate to the local culture?
What resources are available?
What combined methods are needed?
What methods fit the characteristics (age, sex, religion etc) of the
target group?

5.1. How fast do people change?

Some people are ready for change and are economically able to
do the advice easily. For such people provision of information

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 through posters, radio, songs, plays, stories or displays could
suffice.
Some are ready but influence from others could hinder. Direct
contact with such people is the preferred method. E.g. convincing
grandmother for immunization.
For those who are economically unable, linking them with sectors
that help them earn money is a remedy

5.2. How many people involved

Providing good ideas quickly to a large number of people is a very

helpful step in health education. It creates awareness of a problem or
idea. But it may not be enough to change health behavior. Posters,
lectures, display, plays, newspapers, radio, films and village criers are
appropriate for large groups.

Activities such as practicing new skills, discussing personal feelings,

values and money matters, and sharing difficult experiences are best
done person-to-person, or in small groups using story-telling,
demonstrations, role-playing, case studies, discussions and
educational games.

5.3. Is the method appropriate for the local culture?

From the Previous sections, we know that culture is the way of life of
people in a community. Culture will determine the educational
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methods that will be acceptable and understandable to people. Some
methods may not be accepted in one culture while it may be effective
in the others. For example Role-playing, photographs, or films may
not be adaptive to illiterate community. In such communities we can
use the most natural way of communication such as proverbs, village
criers, plays, songs and so on.

Practical demonstrations are good ways of teaching skills. For

example, instead of just talking about hygiene, a health worker can
show mothers how to bath their babies. This would motivate and
enable them practice in the future.

5.4. What resources are needed?

Some methods require the use of machines: tape recorders, films or

slide projectors, which at the same time require electricity. Other
methods require the use of teaching aids such as posters, flannel
graphs, demonstrations, models, flip charts and the like. On the other
hand, some methods require only yourself and the people around
you; these include the use of stories and songs, role-plays, group
discussions, and community meetings.
Therefore, try to look for methods that are inexpensive, culturally
acceptable, understandable, and at the same time effective.
5.5. What combined methods are needed?

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Ideally, use of mix of methods and repetition improves understanding
and people are more likely to remember them. The following
combinations may be used:
Story telling and asking the audience to role-play in which they act
out the story for all to see.
Lecture assisted with posters, films or demonstrations.
Community meeting with displays or short play.

5.6. Which methods fit the group best?

Health education could be designed for various groups of people: old,

young, women groups, children and so on. Select and adapt your
methods to fit the type of people you meet.
Fables using animals might be better for children than for adults.
Lectures are more applied for educated. If the people belong to one
religion, select proverbs from the scriptures on books of that religion.

B. Carry out and Evaluate the Program

1. Development and implementing a program

After having analyzed the situation, define problems, prioritize and set
objectives, identify resources, and design strategy, the health
extension workers and health committee should be able to develop
an action plan. A plan of work is a picture or map of what to do,
when to do it, who will do it, and at what cost each step of activities
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be accomplished. It will serve as a guide and will help in
implementing and evaluating the project and planning another one.

The Plan of Action should include:

Goal and objectives

What steps are to be taken - list of activities
Who will be responsible for each step - person in charge
What materials, equipment, people, funds will be necessary
for each step - resources
When each step is to be completed - target date.

2. Evaluating the program

Evaluation is the process of looking back over what has been done to
be sure that things were done the way they should. Evaluation is not
a one-time event. It is a continuous process how the program is
progressing according to a set time table in the action plan.
Information for evaluation program would be obtained from
observations, interviews, and records.

Following each step or activity, ask questions such as:

How well did we do?

Did the plans work?

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 Why did we succeed? Or fail?
What do we do next?
Did we learn from our mistakes or successes?
By the end of the educational activities, you should be able to
measure their successes by counting how many people are behaving
according to the original objectives: is this number more than before
the program started?
At the end of the program, a final meeting can be held to discuss how
far the program succeeded.
Changes in attitude may be assessed by answering the following
questions:

Did people participate in the project as expected?

Did people gain new skills and learn from the program?
Was there less opposition by groups in the village who had
previously been against the program?

Changes in behavior:
People disposing of feces and urine in latrines
People using clean bucket for gathering water
Increased in visits to the health post.
Increased in the number of children immunized
Increased number of pregnant women seeking early prenatal
care.
Increased in the number of births that occur in the health facilities.
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Exercise

1. Explain how to define and prioritize problems

2. If malaria is a problem of the area you are working, what will
be your educational objectives as part of the control program?
3. How do you get information to evaluate a certain health
education program?

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 UNIT EIGHT
Ethical Issues In Health Education

Objectives

At the end of this chapter, the trainees will be able to:

Define ethics
State basic principles of ethics
Describe the responsibilities of health extension workers to
community.
Describe the responsibilities of health extension workers to the
health extension package.

Introduction

From a profession point of view, ethical behavior is expected from

professionals. Ethical conduct is particularly important for health
educators, since they are working with a mission to serve the
individual. This chapter will try to address:

Definition

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Ethics is the philosophical study of the moral value of human conduct
and the rules that govern it. It is the right thing to do for society and
self. Moral refers to those beliefs about how people ought to behave.
Basic ethical principles

1. The principle of autonomy

This principle means that people, being individuals with individual

differences must have a freedom to choose their own ways and
means of being moral with the framework of the other four principles.

Respect for autonomy involves respecting another persons rights and

dignity such that a person reaches a maximum level of fulfillment as a
human being. In the context of health promotion and health care this
means that the relationship between health extension worker and
community member is based on a respect for him or her as a person
and with individual rights.

Rights in relation to health care are usually taken to include:

The right to information
The right to privacy and confidentiality
The right to appropriate care and treatment

2. Beneficence (doing good)

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Beneficence means doing or promoting good as well as preventing,
removing and avoiding evil or harm.
E.g. provide information about emergency first aid to reduce the
risks of HIV infection or accident.
3. Non-maleficence (doing no harm)

Non-maleficence holds a central position in the tradition of medical

ethics and guards against avoidable harm to subjects. In short, it
refers to non-infliction of harm to others. E.g. use of sterile needles.

4. Justice (fairness)

This principle states that human being should treat other human
being fairly and justly in distributing goodness and badness among
them. In other words justice should include:

Fair distribution of scarce resources

Respect for individual and group rights
Following morally acceptable laws

5. The principle of truth telling (honesty)

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At the heart of any moral relationship, there is communication. A
necessary component of any meaningful communication is telling the
truth, being honest.

Ethics for the performance of health extension workers as health

educators

Health extension workers as health educators assume profound

responsibility in using educational processes to promote health and
influence human well-being. They are also responsible for the
implementation of health extension package program. Ethical
precepts that guide these processes must reflect the right of
individuals and communities to make decisions affecting their lives.

Health extension workers responsibilities as a health educator

Affirm an equal right, believing that health is a basic human right

for all.
Provide people with relevant and accurate information and
resources to make their choices freely and intelligently.
Support change by freedom of choice and self-determination, as
long as these decisions pose no threat to the health of others.
Be advocates for healthful change and legislation, and speak out
on issues deleterious to public health.

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 Avoid and take appropriate action against unethical practices and
conflict of interest situations
Respect the privacy, dignity and culture of the individual and
community and use skills with these values.
Share their skills, experience and vision with their clients and
colleagues.
Observe principles of informed consent and confidentiality of
individuals.
Maintain their highest levels of competence through continued
study, training and research.
Accurately represent their capabilities and education as well as
training and experience and act within the boundaries of their
professional competence;
Ensure that no exclusionary practices be enacted against
individuals on the bases of sex, marital status, color, age, social
class, religion, ethnic background, national origin, or other
nonprofessional attributes in rendering service, employing,
training, or promoting others.

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Exercise

1. Mention basic principles of ethics

2. What are your responsibilities to the community as a
health educator?

119
References

1. John Hubley. Communicating Health, An action guide Health

Education and Health promotion, 2002.
2. WHO, Education for Health. A manual on Health Education in
Primary Health Care, 1988, Geneva, WHO.
3. Jannie N., Jane W. Health Promotion Foundations for
Practice, 2nd edition, UK, 1995.
4. LRamachandran, TDharmalingam. Health Education, A new
approach, New Delhi 1998.
5. EPHA. Public Health Code of Ethics for Ethiopia, July 2003.
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Training of Trainers Guide on Communication and Social
Mobilization for Health Communicators, Jimma Institute of
Health Sciences, Department of community, Jimma, Ethiopia,
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7. Reidulf k.Molvaer. Education for Better Health: A manual for
senior Health Educators, UNICEF/MOH Addis Ababa,
Ethiopia, 1989.
8. Peace corps Information collection and Exchange manual M-
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10. Getnet Mitike. Health Education for Health Science students,
Addis Ababa University, Department of Community Health,
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11. Challi Jira, Amsalu Feleke, Getnet Mitike. Health service
management for Health science students, Jimma University,
Faculty of public Health, 2003 January.
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Principles and foundations of Health Promotion and
Education. Publishers: Allyn and Bacon, 1999.

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